Healthcare Complementary Plan

HEALTHCARE COMPLEMENTARY PLAN

Patient Name:    Date of Birth:    Gender:

Contact and Emergency Information

Insurance Information

Medical History

Complementary Plan Details

Summary of Proposed Complementary Care: This plan outlines non-contradictory, adjunctive therapies to be provided in coordination with the patient’s medical care. Services may include but are not limited to: acupuncture, therapeutic massage, nutritional counseling, herbal support, physical rehabilitation modalities, mind-body techniques, and behavioral coaching.

Insurance Coverage: I certify that I have informed the provider of expected insurance coverage for complementary services. I understand that I remain financially responsible for services not covered by my insurer.

Risks, Benefits, and Limitations

The patient acknowledges that complementary therapies carry potential benefits and risks. Benefits may include symptom relief, improved function, and enhanced well-being. Risks may include allergic reactions, transient pain, bruising, interaction with medications, or lack of improvement. The provider has disclosed material risks and typical adverse events associated with the proposed services.

Limitations: Complementary therapies are adjunctive and do not replace acute medical or emergency care. The provider will coordinate with the patient’s primary care or treating clinicians as appropriate, but responsibility for overall medical management remains with the treating medical clinicians.

Acknowledgement of Risks: I acknowledge that I have been informed of the risks and potential benefits and that I have had an opportunity to ask questions.

Patient Rights and Withdrawal

Participation is voluntary. The patient may withdraw consent for any or all elements of this complementary plan at any time. Withdrawal will not adversely affect the patient’s access to other services. Upon withdrawal, the provider may document the change in the patient’s record and notify other treating clinicians if necessary for continuity of care.

Right to Withdraw Acknowledgement: I understand my right to withdraw consent and have been informed of the procedure for doing so.

Privacy and Authorization

HIPAA Notice & Authorization: By signing below I authorize disclosure of my protected health information to the complementary care providers listed in this plan as necessary for treatment, coordination, billing, and quality assurance. I understand that information disclosed may include diagnoses, medications, and treatment notes relevant to the complementary therapies. This authorization is voluntary and may be revoked in writing except to the extent that action has already been taken in reliance on it.

Acknowledgement of Privacy Practices: I acknowledge that I have received or been offered the provider’s privacy practices and understand how my health information will be used and disclosed for the purposes described.

Certifications and Consent

By signing below I certify that the information I have provided is true and complete to the best of my knowledge. I consent to participate in the complementary care plan as described above. I understand the scope, potential benefits, risks, alternatives, and financial responsibilities associated with this plan. I authorize those named providers to proceed with the described complementary therapies and to communicate with my medical care team as necessary.

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